The KDIGO Clinical Practice Guideline for the Care of Kidney Transplant Recipients

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The KDIGO Clinical Practice Guideline for the Care of Kidney Transplant Recipients was the third Kidney Disease: Improving Global Outcomes (KDIGO) guideline, published in November 2009 as a supplement to the American Journal of Transplantation. This guideline addressed a broader set of issues than did the previous two guidelines (for hepatitis C and bone and mineral disease). The guideline was written for clinicians (doctors, nurses, coordinators, and pharmacists) providing care to patients who have received a transplant. It was also aimed at a diverse audience, including those in both the developed and the developing worlds. To limit its scope, the guideline focused on the post–kidney transplantation period and did not delve into issues related to the potential candidates for kidney transplantation, donors (living or deceased), or any other transplanted organ. The guideline also focused on issues that are unique to kidney transplant recipients. The purpose of the guideline was to improve patient care by helping clinicians base their management on available evidence, and it was developed to enable the development of transplantation programs worldwide. Finally, the literature review and analysis provided an opportunity to identify knowledge gaps and define the areas that needed further exploration and research.

The guideline covers a broad range of topics, including immunosuppression (induction therapy, initial and long-term maintenance medications, strategies to reduce drug costs, and immunosuppression monitoring); treatment of acute rejection; treatment of chronic allograft injury; monitoring allograft function; kidney allograft biopsy; recurrent disease; nonadherence (prevention, detection, and treatment); infectious disease issues (vaccination; viral diseases including BK virus, cytomegalovirus, Epstein-Barr virus, and posttransplantation lymphoproliferative disease; herpes simplex 1 and 2; varicella; hepatitis B and C; HIV; urinary tract infections; pneumocystis; and Candida infections); diabetes mellitus (screening for and managing new-onset diabetes after transplantation and preexisting diabetes mellitus); hypertension; dyslipidemia; tobacco use; obesity; cardiovascular disease management; malignancies (cancer of the skin and lip, non–skin malignancies, managing cancer with immunosuppression reduction, transplantation bone disease, and hematologic complications); hyperuricemia and gout; pediatric topics (growth and development); sexual function; female and male fertility; lifestyles; and mental health.

Like the other KDIGO management guidelines, this one was developed on the basis of a systematic review of relevant treatment trials. The recommendations were articulated by use of the Grading of Recommendations Assessment, Development, and Evaluation system. This entails having each guideline accompanied by a grade indicating the strength of the recommendation and also an assessment of the quality of the literature on which the recommendation is based. The strength of the recommendation is indicated as Level 1 (indicated as “we recommend”), Level 2 (“we suggest”), or not graded. The quality of the supporting evidence is depicted as A (high-quality evidence), B (moderate-quality evidence), C (low-quality evidence), or D (very-low-quality evidence).

Only 2 percent (4 recommendations) were graded A (having highest-quality evidence), 13.6 percent (27) were graded B (moderate-quality evidence), 38.9 percent (77) were graded C, and 45.5 percent (90) were graded D. The quality of evidence directly affected the strength of the recommendation. Consequently, of all the graded statements only 25.3 percent of the recommendations were afforded a Level 1 recommendation (we recommend) and the remaining 74.7 percent were assessed as Level 2 recommendations (we suggest).An additional 45 recommendations were not graded.

The KDIGO Clinical Practice Guideline for the Care of Kidney Transplant Recipients was published more than 3 years ago, and the initial work on it started more than 6 years ago. No doubt some of the guideline needs updating. With this in mind, what follows are my pick of some of the helpful recommendations for the “nontransplantation” nephrologist. They focus primarily on long-term management issues. There are many other useful recommendations, but these give a flavor of some of the important topics that are covered by the KDIGO guideline.

Issues related to long-term maintenance immunosuppression medications are covered, and sample recommendations include:

3.2: We suggest that calcineurin inhibitors be continued rather than withdrawn (2B).

3.2: If prednisone is being used beyond the first week after transplantation, we suggest prednisone be continued rather than withdrawn (2C).

Strategies to reduce drug costs are also touched on, and include this important recommendation:

4.4: After switching to a generic medication that is monitored using blood levels, obtain levels and adjust the dose as often as necessary until a stable therapeutic target is achieved (not graded).

Monitoring immunosuppressive medications is also discussed, including the following recommendation:

5.1: We recommend measuring blood levels of calcineurin inhibitors (1B) and suggest measuring at least:

  • whenever there is a change in medication or patient status that may affect blood levels (2C);

  • whenever there is a decline in kidney function that may indicate nephrotoxicity or rejection (2C).

In terms of chronic allograft injury, the KDIGO guidelines state:

7.1: We recommend kidney allograft biopsy for all patients with declining kidney function of unclear cause, to detect potentially reversible causes (1C).

With regard to monitoring kidney allograft function:

8.3: We recommend measuring serum creatinine (1B) at least

  • every 2 weeks for months 4 to 6 (2C).

  • monthly for months 7 to 12 (2C).

  • every 2 to 3 months thereafter (2C).

There are many other useful recommendations in this comprehensive KDIGO document. The guideline is presented in a practical format. Each area and chapter includes a focused discussion of the background, rationale, and research recommendations that emerge from the recommendations and level of evidence available. The guideline includes references and an appendix that outlines the approach and an analysis of the available papers. In the end, it achieves what was intended—“it addresses issues that are important to the care of [kidney transplant recipients] in both developed and developing countries.” As well, it serves as a useful resource for all of us in the transplantation field.

Michelle A. Josephson, MD, is the chair of ASN’s Transplant Advisory Group and is affiliated with the department of medicine, section of nephrology, at the University of Chicago. She was a Work Group Member for “KDIGO Clinical Practice Guideline for the Care of Kidney Transplant Recipients.”